The use of percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) for the treatment of left main coronary artery disease (CAD) of low or intermediate anatomic complexity were found to be associated with comparable rates of a composite of death, stroke, and myocardial infarction (MI) at 5 years, according to a study published in the New England Journal of Medicine.
Patients with stenosis of the left main coronary artery of ≥70% or between 50% and 70% were enrolled in the study (n=1905). Patients were randomly assigned to receive PCI with fluoropolymer-based cobalt-chromium everolimus-eluting stents (n=948) or CABG (n=957). A composite of death, stroke, or MI at 3 years was the study’s primary outcome. Secondary outcomes included the primary outcome at 30 days as well as a composite of death, stroke, MI, and ischemia-driven revascularization at 3 years. The composite outcome measures were also assessed at 5 years, in addition to therapy failure, all revascularizations, and all cerebrovascular events.
The primary composite was found to be comparable for the PCI and CABG groups at 5 years (22.0% vs 19.2%, respectively; difference, 2.8 percentage points; 95% CI, −0.9 to 6.5; P =.13). There were more deaths from any cause in the PCI vs CABG group (13.0% vs 9.9%, respectively; difference, 3.1 percentage points; 95% CI, 0.2-6.1). The incidences of definite cardiovascular death (5.0% vs 4.5%, respectively; difference, 0.5 percentage points; 95% CI, −1.4 to 2.5) and MI (10.6% vs 9.1%, respectively; difference, 1.4 percentage points; 95% CI, −1.3 to 4.2) were also comparable between the PCI and CABG groups.
There were fewer cerebrovascular events after PCI vs CABG (3.3% vs 5.2%, respectively; difference, −1.9 percentage points; 95% CI, −3.8 to 0). The incidence of stroke was also similar between the PCI and CABG groups (2.9% vs 3.7%, respectively; difference, −0.8 percentage points; 95% CI, −2.4 to 0.9). Patients in the PCI vs CABG group had more ischemia-driven revascularization following intervention (16.9% vs 10.0%, respectively; difference, 6.9 percentage points; 95% CI, 3.7-10.0).
Limitations of the study include the relatively short duration of follow-up (5 years), as well as the open-label design.
“Ten-year (or longer) follow-up is needed to characterize the very late safety profiles of PCI and CABG, since both stents and bypass grafts progressively fail over time,” concluded the study authors.
Disclosure: This clinical trial was supported by Abbott Vascular. Please see the original reference for a full list of authors’ disclosures.
Stone GW, Kappetein AP, Sabik JF, et al; EXCEL Trial Investigators. Five-year outcomes after PCI or CABG for left main coronary disease. N Engl J Med. 2019;381(19):1820-1830.